Exploring the Help Seeking Experiences of Family Members Affected by Someone Else’s Drug and/or Alcohol use

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EXPLORING THE HELP-SEEKING EXPERIENCES OF

FAMILY MEMBERS AFFECTED BY SOMEONE ELSE’S

DRUG AND/OR ALCOHOL USE.

FIONA DOWMAN

A thesis submitted in partial fulfilment of the requirements of the

University of East London for the degree of Professional Doctorate in

Clinical Psychology

May 2017

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AKNOWLEDGEMENTS

First and foremost, I would like to express my gratitude to the eleven people who gave up their time to speak with me so candidly about their experiences of being affected by someone else’s drug or alcohol use. I am grateful to the managers at the third sector organisation who kindly allowed me to collect data at their site. An extended thanks to the staff at the third sector site who made me feel welcome during my time there conducting interviews.

Thank you to my thesis supervisor Dr Poul Rohleder for your valuable advice, feedback and supervision. Thanks to Dr Meredith Terlecki for her supervision in the early stages, helping me conceptualise my initial ideas.

My profound gratitude goes to Dr Lisa Dutheil for her enthusiasm about my initial ideas for this research and for putting me in contact with third sector

organisations. Further thanks for your continuous support and guidance throughout my doctorate journey. Your kindness knows no bounds!

As my clinical training draws to a close - what has been a most challenging endeavour, I would like to thank my parents, Lennox and Yvette for never doubting my capabilities and equipping me with the resilience not to give up in the face of obstacles, enabling me to achieve what I have, to date!

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[ii] ABSTRACT

Background & Aims: The impact of an individual’s drug or alcohol use on their family members has been widely acknowledged and policy and clinical practice guidelines advise that drug and alcohol services offer family members practical and therapeutic support. However, research in this area is limited with a focus on the experiences of children affected by parental drug and alcohol use or how family members can help improve outcomes for their relatives in treatment for drug and alcohol use. Little is known about the experiences of affected adult family members in receipt of support services for themselves. The current

research aimed to explore the impact that having a relative who uses drugs and/ or alcohol had on family members’ lives as well as affected family members’ experiences of seeking help for themselves. Method: Semi structured interviews were carried out with eleven adults affected by a family member’s drug and/or alcohol use and receiving support from a family, partners and friends service in London. Interviews were transcribed verbatim and analysed using thematic analysis (TA), informed by Braun and Clarke’s (2006) six-phase model of TA and underpinned by a critical realist epistemology. Results: The analysis produced five main themes across the data. Each indicated important factors in the journey of having a relative who uses drugs or alcohol. The themes were: ‘family

members’ distress’; ‘ruptures in relationships’; ‘responsibility’; ‘routes to receiving help’ and ‘relieving the pressure’ Conclusion: The results of the analysis

highlight the multi-faceted impact of drug and alcohol use on affected family members’ lives as well as the ways that services could help to facilitate help seeking. Findings support previous literature surrounding affected family

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List of Abbreviations

FPF Family, Partners and Friends

SSCS model Stress-Strain-Coping-Support model

IAPT Improving Access to Psychological Therapies NHS National Health Service

NICE National Institute for Health and Care Excellence

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Numerous theories and studies have indicated that an individual’s drug or alcohol use has a negative impact on their family and the systems around them (Orford, Velleman, Copello, Templeton & Ibanga, 2010). Although literature exploring these negative impacts is steadily growing, more is known about the impact of parental substance use on children than there is about the impact of drug and alcohol use on adult family members (Copello, Velleman & Templeton, 2005) and little is known about the help-seeking experiences of affected family members. This research set out to explore the effects of adults’ drinking and drug use on their adult family members and the help seeking experiences of those affected family members.

1.1. Overview of the Chapter

In this chapter I will outline definitions of drug and alcohol use. I will go on to set the context by describing prevalence rates and relevant statistics with regards to those who use drugs and alcohol and those who are affected. This will be followed by a critical review of relevant theory, research and policy. I will conclude the chapter with a rationale for the current study, the research aims and questions.

1.2. Drug & Alcohol use in the UK

1.2.1. Language

I have opted to write in the first person, in keeping with the aim for reflexivity in qualitative research (Webb, 1992). Inverted commas have been used to denote words that have multiple interpretations or are contested.

1.2.2. Terminology

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substance taking behaviour, tolerance, withdrawals and persistent substance use despite harmful consequences (DOH, 2012). Addiction has been defined as‘not having control over doing, taking or using something to the point where it could be harmful to you’ (NHS.uk, 2015).

The terms ‘addiction’ ‘misuse’ ‘abuse’ and ‘dependency’ are viewed by many as having moral, value laden connotations and implications about social unacceptability (Ghodse, 2005). Furthermore, there is ambiguity in the literature about what is meant by these terms, sometimes it denotes frequency and quantity of use, sometimes it denotes nature of use (i.e. illegal drug). In an effort to avoid conceptual ambiguity and value judgements, I have opted to use the terms: ‘drug or alcohol use’ or ‘drinking’ throughout this thesis. In the literature review, it will be noted whether research is about alcohol or drugs and the type of drug, where the information is available.

1.3. Prevalence of Drug & Alcohol Use in the UK

‘Problematic’ drug and alcohol use is deemed to be an individual and public health issue in the UK and worldwide (HM Government, 2010; World Health Organisation, 2007; 2016), associated with health, economic and social harm; such as poverty, family breakdown and crime. In 2015-16, an estimated 2.7 million adults (aged 16-59) in England and Wales had taken an illicit drug in the last year and 11.4 million adults (aged 16-59) had taken an illicit drug in their lifetime (Home Office Statistics, 2016). The prevalence of illicit drug use in England and Wales has been measured by the Crime Survey for England and Wales (Home office Statistics, 2016). It is an annual household survey of a nationally representative sample of adults (aged 16-59). In 2015-16 the most commonly used drug in England and Wales was cannabis with around 2.1 million adults reporting to have used it in the last year (Home Office Statistics, 2016). After cannabis, the second most commonly used drug in the last year was reported to be cocaine powder with around 725,000 adults having used it.

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known as ‘legal highs’ in the last year. Fewer than 1 in 100 adults which equates to 244,000 adults. The drugs that were reported to be the least commonly used were opiates (0.1%), crack cocaine (0.1%) and methamphetamines (0.0%). These figures only highlight how many people report to have used specific drugs in a one year period rather than how often they were used in that year or whether the use was deemed to be problematic. Given that these figures are based on a self-report measure, it is worth considering whether they reflect the social

acceptability of reporting cannabis use and the under reporting of other drugs such as crack cocaine and opiate use due to lower social acceptability (Home office Statistics, 2016). Furthermore, ‘problematic’ opiate and crack cocaine use can lead to people being marginalised and becoming homeless or

institutionalised (United Nations Office on Drugs and Crime, 2017). Therefore, people who use these drugs may not be captured in surveys sent out to ‘typical’ households.

Data from a self-report survey shows that in 2014, 12.5 million adults over the age of 16 in Britain reported to have consumed more alcohol than the weekly low risk threshold and 2.5 million reported to have consumed more than the

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59,873 were treated for alcohol use alongside other substances (Public Health England, 2016).

1.4. International Prevalence of Drug & Alcohol Use

The World Health Organisation (WHO) statistics show that alcohol is consumed worldwide, though the rates of consumption and level of health impact vary

between countries. In general, more alcohol is consumed in countries which have the greatest economic wealth (WHO, 2014). Recorded data on annual alcohol sales show that compared to the rest of the world, during the year 2013, the UK had relatively high rates of alcohol consumption per person along with countries such as Australia, Belgium and Spain (OECD Health statistics, 2015). The highest rates of alcohol consumption in the year 2013 were recorded in Estonia, Austria, Lithuania and the Czech Republic. The lowest rates of alcohol

consumption were recorded in India, Turkey, Israel and Indonesia where alcohol consumption is restricted among some populations due to religious and cultural traditions (OECD Health statistics, 2015).

Globally, an estimated 255 million adults aged 15-64 used an illicit drug at least once in the year 2015 (United Nations Office on Drugs and Crime, 2017). This equates to about 5 per cent of the world population. Of those, 29.5 million were considered to exhibit problem drug use (regular use, drug use ‘disorder’ or ‘dependence’). Cannabis was the most used drug worldwide based on a self-report questionnaire, followed by amphetamines, ‘misuse’ of pharmaceutical opioids, ecstasy, opiates (heroin and opium) and then cocaine. Opioids including heroin were associated with the most negative health impact and globally, on average, more people received treatment for cannabis and opioid use than other drugs (United Nations Office on Drugs and Crime, 2017). Of note, what

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South-West and Central Asia and Eastern and South-Eastern Europe. There were high numbers of people in treatment for Cannabis and Cocaine use in Latin America and the Caribbean. The majority of people receiving treatment for drug use in Africa was for cannabis use (United Nations Office on Drugs and Crime, 2017). The above data represents the best data available from member states submitted to the United Nations through an annual report questionnaire. However, there are variations in the methodology used and quality of data available from different countries.

It is reasonable to infer from the statistics outlined above that for each individual who uses drugs and alcohol there are likely to be large numbers of family

members and other significant people in their lives. Nonetheless, drug and alcohol theories and interventions continue to focus on the individual using drugs or alcohol despite the significant impact of an individual’s drug or alcohol use on the people close to them (Copello & Orford, 2002; Copello & Walsh, 2016).

1.5. ‘Affected Others’ 1.5.1. Prevalence

The adults affected by somebody else’s drug or alcohol use are an

underacknowledged group (UK Drug Policy Commission, 2009). Therefore, the number of adults in the UK affected by somebody else’s drug use is unknown and it has been argued that this is due to the individualistic nature of drug

treatment services and the associated lack of routine data collection about family members (Copello, Templeton & Powell, 2010). However, in 2008 the UK Drug Policy Commission (UKDPC) developed a model to estimate that at the very least nearly 1.5 million adults were significantly affected by a relative’s drug use based on adults living with a person who is ‘dependent’ on an illicit drug (opiates, crack cocaine, cocaine powder and cannabis) and who were not themselves, using illicit drugs (UKDPC, 2009; Copello, Templeton, & Powell, 2009, 2010). The authors acknowledge that this is likely to be an underestimate as it does not capture adults who are not living with their family member but who are

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of alcohol. However, it can be assumed that the estimates of people affected by alcohol use is significantly higher given that alcohol use is more prevalent than drug use in the UK (UKDPC, 2009).

1.5.2. Societal Costs

The cost of harm that families affected by relatives’ opiate or crack cocaine use experience in the form of financial and health care costs has been estimated at about £1.8 billion per year in the UK (Copello et al., 2009; UKDPC, 2009). Moreover, the support that they provide would cost the NHS or local authorities about £750 million if it were not provided by family members. These estimates were produced with limited information sources on which to base them on so are intended to be conservative estimates. In the absence of any robust UK

evidence, the £1.8 billion per year figure was produced by applying data from the United States to the UK to examine average annual financial costs per family member and average excess annual healthcare costs per family member. These figures were then applied to the number of family members estimated to be affected; costs were only attributed to partners and parents as they were estimated to provide most of the care. Family members provided health and social care resource savings through providing support such as accommodation and detoxification at home. Financial costs incurred by family members included day to day financial support, money given to relatives to help them obtain drugs, crime on family members (e.g. theft to fund drug use), loss of employment opportunities and affected family members’ own health care costs due to the stressors associated with drug use within the family. Research in the United States has found that the physical and psychological impact that an individual’s drug or alcohol use had on family members was associated with an increase in family members’ use of health care services (Lennox, Scott-Lennox & Holder, 1992; Ray, Mertens & Wiesner, 2007).

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figures provide a starting point for understanding the cost of harm to families within the UK and highlight the enormity of the impact drug and alcohol use can have on affected others as well as the economic value of the support they provide.

1.6. Policy

Historically UK policy has focused individualistically on intrapsychic effects and solutions to drug and alcohol problems. Any brief mention of families pertained to the ways that families were part of the problem rather than the solution or any reference to their own wellbeing (Velleman, 2010). There has been a recent shift in acknowledgement of families within national and local drug and alcohol policy including the drug strategy, alcohol strategy and the recovery agenda (HM Government, 2012; HM Government, 2010; UKDPC, 2008). It is promising that the national drug strategy makes some reference to the need to consider “…the provision of support services for families and carers in their own right” (HM Government, 2010; p21). However, there is more of a focus in policy on how families can be utilised as a vehicle for enhancing the entry, retention and outcomes of people using drugs and alcohol in treatment as opposed to the needs and experiences of affected others in their own right (Copello &

Templeton, 2012). This could potentially hide the individual needs of the people within the support network of people who use drugs or alcohol. Similarly to what has been noted in literature regarding carers of people with mental health

problems (Oyebode, 2003), concerned and affected others are likely to be in a better position to support the person using drugs or alcohol if their own wellbeing is also considered.

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The national alcohol strategy includes a similar narrative around protecting children from ‘troubled families’ (HM Government, 2012) There is no doubt that these are important measures to take. However, Velleman (2010) argues that to focus solely on children neglects the needs of other family members who are affected and misses an opportunity to support other adult affected family members which in turn is likely to contribute to the wellbeing of children. Treatment for heroin and crack cocaine use has been a political priority due to the harms associated with their use. The ‘Harm reduction’ discourse within government policy (HM Government, 2010) focuses on drug-related harms to individuals and society. Strategies to reduce harm include substitute prescribing, and needle exchanges, preventing drug related deaths and the spread of blood borne viruses. Currently, ‘harm reduction’ is approached at an individualistic level. Arguably, supporting family members would also reduce harms from the impact of an individual’s drinking and drug use on their family member’s health and psychological wellbeing. Improved relationships with family members, friends and partners is acknowledged as one indicator of recovery (HM Government, 2010). More research into the ways that family members are affected by their relatives’ drinking and drug use will aid understanding of how relationships can be improved.

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The National Treatment Agency (2008) and The National Institute for Health and Care Excellence (NICE, 2011; 2007) guidelines have acknowledged the need to support adult family members and significant others in their own right. However, the translation of these guidelines in practice is variable across England and Scotland (Copello & Templeton, 2012). The NICE guidelines (2011; 2007), recommend drug and alcohol treatment services offer family members a carer’s assessment, guided self-help, information and advice but there is a lack of consistent practice based evidence for what works. Family interventions are not implemented in routine practice (Fals-Stewart & Birchler, 2001; Williams, 2004). Furthermore, research has found that relationships between services, policy makers and carers of people with drug and alcohol problems in Scotland is poor (Orr, Barbour & Elliott, 2014). Interviews and focus group data revealed a

dominant narrative among service providers and policy makers of carers being part of the problem. In this study carers were defined as someone over the age of 18 who self identifies as being responsible for the care of someone who uses drugs and/or the children of the individual who uses drugs. Narratives were filled with constructions of carers as unable to provide reliable and consistent support for their relative who was using drugs due to their own issues such as fractured relationships, poverty and unemployment. Subsequently carers felt

misunderstood and unconvinced that services wanted to engage with them. This created barriers to family involvement with drug services and led to poor

communication between adult drug services and carers.

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for some was perceived as a threat to family provision and to some an

opportunity to put more in place for families. These findings raise questions about what would help significant others to access support and what that support

should look like.

In summary, the needs of the large number of family members affected by a relative’s drinking or drug use has been acknowledged. As such, policy and guidelines encourage service providers to support affected others. I will now provide a review of the relevant literature that has been published in this area.

1.7. Literature Review

1.7.1. Literature Search Strategy

I searched the following databases for literature concerning people affected by somebody else’s drug and/or alcohol use: PsycINFO, PsycARTICLES and CINAHL Plus. The search was filtered by the year of publication (1980 to March 2017) to reflect the time frame that research into the experiences of family members affected by relatives’ drug and alcohol use began to emerge. The search yielded 3,477 results. After duplicate articles and articles not relevant to the topic of the current research were discarded there were 79 articles left which were reviewed. I also searched Google Scholar and grey literature for articles relevant to themes mentioned in the core articles. Due to the paucity of UK based studies in this area, the search was not restricted to studies carried out in the UK but was limited to work written in the English language. Search terms used included variants of the word ‘family’ combined with a variant of ‘drug’ or ‘alcohol misuse’ and ‘help-seeking’ (see appendix A for a full list of search terms).

1.7.2. Structure of the Literature Review

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ways that family members are affected, the interventions available to them and discuss relevant help-seeking theories and research.

1.8. Historical Research into Families Affected by Drugs and Alcohol 1.8.1. Pathology Models

Historically, family members have been viewed negatively within the dominant discourse of the literature (Orford et al., 2005). Within pathology models, families are viewed as the cause of drug and alcohol problems whereby pathology within the family environment serves to develop and maintain the problem. Factors such as genetic risk, family structure and parent-child relationships have all been described as contributors to the development and maintenance of drug and alcohol problems (Bierut, et al.,1998; Selnow, 1987). Many studies which support genetic risk factors for drug and alcohol use in families downplay environmental factors (Guze, Cloninger, Martin & Clayton, 1986; Pickens et al., 1991). For example, Bierut and colleagues (1998) conclude from their research that alcohol, marijuana and cocaine ‘dependence’ are ‘transmitted’ within families. Conclusions of genetic causality were drawn from correlations which showed that siblings of people with ‘alcohol and substance dependence’ had an increased risk of developing ‘alcohol and substance dependence’ compared to siblings of people in a control group. Although they considered and clarified in their analysis that the results were not confounded by family members supplying drugs to their siblings, this is a narrow lens on the many potential social and environmental influences on drug and alcohol use within families such as shared stressors, availability of drugs within their shared environment and the influence of peers.

1.8.2. Co-dependency

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occupied with their relationship with the other person and as ‘addicted’ to the person needing them (Heineman, 1987).

The co-dependency construct has been critiqued for having sexist assumptions, stereotypical biases and for victim blaming (Decker, Redhourse, Green & Starrett, 1983). It is argued to be a disease model applied to interpersonal relationships which can be internalised as an identity and character flaw and have a negative impact on wellbeing (Anderson,1994).

Orford and colleagues, argue that “although some of these ‘pathology’ notions are now of historical interest, the underlying idea that family members contribute to the problem has not gone away” (2005; p6). In contrast, Copello and colleagues strongly advocate for non-pathologising models of the family and interventions designed to support family members with the effect that their relatives drug and alcohol use has on them rather than to treat family members’ own ‘pathology’ (Copello, Templeton, Orford, & Velleman, 2010a). This will be discussed in more detail later in the chapter.

1.9. Family Systems Theory

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This allows families to see how they function during periods of drug and alcohol use and abstinence which could enable them to engage in patterns of behaviour that support abstinence. However, this model assumes that there are correct and incorrect ways to respond to a relative’s drinking or drug use. It emphasises the whole family system rather than the impact of drug and alcohol use on individual family member.

1.10. Impact of Drug Use on Adult Family Members

There is growing evidence for the negative impact of an individual’s drug and alcohol use on their relatives in the UK, predominantly carried out by a small team of researchers (Copello & Walsh, 2016; Orford et al., 2005; Velleman, et al., 1993) and in other countries (Arcidiacono, et al., 2010; Berends, Ferris, & Laslett, 2012 & 2014; Csiernik, 2002; Dussaillant & Fernandez 2015; Hussaarts, Roozen, Meyers, van de Wetering, & McCrady, 2012: Selbekk & Sagvaag, 2016). The stresses experienced by families from the effect of drug or alcohol use has been found to be similar across cultures (Arcidiacono, Velleman, Procentese, Albanesi & Sommantico, 2009; Orford et al., 2005; Velleman & Templeton, 2003).

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asked if they drink or use drugs. This information would help to assess whether family members’ experiences may be influenced by their own drinking or drug use.

Drug and alcohol use has been found to have a multi-faceted impact on people who use drugs and alcohol and the systems around them (Copello et al., 2005), affecting areas such as physical and psychological wellbeing, social life, employment, relationships and finances. Research as early as the 1980s found an individual’s drinking to impact the emotional wellbeing of significant others. For example, Jung (1986) gave questionnaires to college students about a ‘problem drinker’ they were affected by. The majority of affected others in the study reported that they drank alcohol themselves, but on the whole, reported to have drunk less frequently and less on each occasion (lower quantity) than their significant other who they viewed subjectively as a problem drinker.

Severity of the impact of an individual’s alcohol use on family members has been found to be significantly associated with them living together (Berends, Ferris, & Laslett, 2012). This study highlights the negative impact of alcohol use on family members across a large geographical spread of participants in the general population in Australia. Through telephone surveys, 415 respondents who responded yes to having a family member who was a ‘fairly heavy drinker’ or ‘drinks a lot sometimes’ were asked closed ended questions about whether and how often they had been negatively impacted in a certain way in the last 12 months. The description of the methodology does not mention asking participants about their own drinking. Therefore, the participants own drinking has not been ruled out as a confounding variable impacting the severity of their negative experience. These findings are relatively comparable to the UK as rates of drinking in Australia have been found to be similar to drinking rates in the UK (OECD Health statistics, 2015).

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2007). Results from a study carried out in Germany suggests that treating alcohol use with detoxification reduces family financial burden and improves quality of life (Salize, Jacke, Kief, Franz, & Mann, 2013). Financial burden and quality of life were only measured one year after detoxification, so the results do not indicate whether improvements were sustained.

Research has found that supporting family members can have a positive effect on their psychological wellbeing (e.g. Miller, Meyers & Tonigan, 1999; Roozen, de Waart, & van der Kroft, 2010) and in turn enhance the wellbeing of their relative who uses drugs or alcohol. Consistent with the systemic notion of

circularity (Guttman, 1991), the wellbeing of people who drink or use drug is likely to further enhance their family members’ wellbeing.

1.10.1. Stress-Strain-Coping-Support Model

The Stress-strain-coping-support (SSCS) model was developed in the UK by Orford, Copello and colleagues (Orford, Templeton, Velleman & Copello, 2005; Orford, Copello, Velleman & Templeton, 2010) as an alternative to pathology models and systemic models which the researchers argued are both blaming of affected family members, centring on dysfunction within the relationship. In contrast the SSCS model aims to be a non-blaming approach to understanding the needs of affected family members and social networks, in their own right. The premise of the model is that family members are understood to be ordinary

people affected by the stress of their relative’s drinking or drug use. The family members engage in a number of behaviours in response, which are described by the model as ‘methods of coping.’ Three methods of coping are described:

‘putting up’ (e.g. accommodating or tolerating drug or alcohol use), ‘withdrawing’ (e.g. distancing oneself, distraction, focussing on one’s own needs) and ‘standing up’ (e.g. efforts to control their relative’s drinking or drug use, no longer tolerating it). Family members often experience dilemmas about how to cope often

oscillating between engaging with their relative’s drug use problems or leaving them to their own devices (Velleman et al., 1993). The way in which family members cope with the situation impacts on the level of physical and

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members’ ability to cope through providing knowledge and developing and enhancing social and professional support is imperative for reducing affected family members’ stress and strain. Good quality social support has been found to act as a buffer against ill health (Cohen & Wills, 1985). The 5-step intervention, discussed later in this chapter, was born out of the SSCS model as a way to address affected family members’ individual needs.

The SSCS model has been tested using standardised measures (Orford et al., 2005) and recently received support from a study conducted in Greece which reported that families respond to their relatives’ drinking or drug use in ways consistent with the SSCS model (Fotopoulou & Parkes, 2017).

1.10.2. Health Impact

Family members of individuals who use drugs and alcohol have been found to have a heightened risk of physical and psychological health problems (Benishek, Kirby & Dugosh, 2011; Orford, 1990; Orford et al., 2010; Ray et al., 2007; Roberts & Brent, 1982; Wiseman, 1991). Adult family members living with a relative who is drinking or using drugs repeatedly obtain high mean scores on the Symptom Rating Test (SRT): a standard measure of general ill-health (Orford, Velleman & Copello, 2005).

It has been argued that the significant global impact of drug and alcohol use on affected family members’ ill health has been neglected by research and policy (Orford, Velleman, Natera, Templeton & Copello, 2013). Quantitative and qualitative cross cultural data collected from the UK, USA, Mexico and Australia, has revealed that affected family members commonly referred to health complaints such as poor eating and sleeping, an increase in their own substance use such as tobacco smoking and use of prescribed medication and physical health symptoms (e.g. headaches, hypertension, asthma, palpitations and back pain) (Orford et al., 2013).

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controls who’s relative had been diagnosed with asthma or diabetes, family members affected by a relative’s drug or alcohol use were more likely to be diagnosed with ‘trauma’, ‘depression’ or ‘substance dependency’ and had higher healthcare costs than family members of people with diabetes or asthma over a three-year period. Although causation cannot be inferred from the results, the fact that family members of people diagnosed with ‘drug or alcohol dependency’ were consistently more likely to be diagnosed with ‘depression’, ‘trauma’ and ‘substance dependency’ suggests there may be unique stressors associated with having a family member with a drug or alcohol problem. Alternatively, the findings could reflect that affected family members of people who use drugs or alcohol are more likely to receive these diagnoses because they are in contact with mental health and drug services when accompanying their relative or they are more likely to seek help for their mental health than family members of people with physical health conditions.

1.10.3. Family Relationships

Research has found that an individual’s drug use can cause huge strain on relationships within the family and lead to a distortion of roles within the family dynamic (Barnard, 2006). For example, the findings from a large telephone survey carried out in Australia revealed that being emotionally hurt and having serious arguments were commonly reported by family members of people who use alcohol in the general population (Berends, Ferris & Laslett, 2014). A study utilising the same data found that those who described themselves as taking on a caring role due to their family member’s drinking reported a lower quality of life than those who did not (Jiang, Callinan, Laslett & Room, 2015).

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attempted to contain and manage the drug use, whilst maintaining a ‘normal’ family life, the negative impacts of the drug use created strain in the form of arguments, drugs being the centre of attention, theft, violence, stress and anxiety. Eventually families excluded the person with the drug problem. Furthermore, role differences between parents and siblings mediated the impact that the drug use had. Parents generally felt responsible for the family including their adult son or daughter using drugs. Whereas the sibling role did not carry the same level of responsibility. However, in a family where parents’ attention is diverted to the sibling who uses drugs, brothers and sisters mourned the loss of a supportive, positive, protective relationship they would expect in a ‘normal’ sibling relationship. However, what was shared between parents and siblings was stress and worry about the wellbeing of their family member who was using drugs. This research highlights the importance of considering the nature of relationships and role expectations when doing research into drugs and alcohol and the family.

Some research has found that an individual’s heavy drinking does not have a negative impact on their partner’s quality of life (Orford & Dalton, 2005; Livingston, 2009). This could be due to methodological differences such as the use of self-report questionnaires and surveys that measure drinking consumption but do not capture pattern or context of drinking. The ‘problematic’ nature of the drinking may be more important than the quantity of consumption or there may be potential benefits of the alcohol’s effect (e.g. inducing positive moods and sociability).

1.10.4. Social Networks Beyond the Family

It is worth considering that wider social networks, outside of the family, can be affected by somebody’s drug or alcohol use and in turn impact upon the individual using alcohol or drugs. Room and colleagues (2010) for example, highlight the harms to an individual’s social environment as a result of drinking. It is possible for a neighbour, a colleague or a friend to deem themselves adversely affected by the drinking or drug use of somebody else. However, less is known about this.

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were deemed by family members as being unsupportive due to factors such as being critical and demonstrating a lack of understanding (Orford et al., 2010). Many expressed finding it more helpful to speak to people who have been through a similar experience and are therefore deemed as more likely to understand.

1.11. Family Oriented Interventions

I have thus far outlined evidence for the impact of drug and alcohol use on family members. However, despite the overwhelming evidence, support available for family members is sporadic and ill defined (Orford et al., 2013). Qualitative interviews with commissioners and service providers in England and Scotland revealed that there was significant variation in service provision for families and carers across services. Provision varied from carers involvement with needs assessments, service review and monitoring to support groups for family and carers and there was little emphasis on training a workforce to deliver evidence based interventions to adult family members (Copello & Templeton, 2012).

Velleman and Templeton (2002) posit that the majority of interventions that have been designed with affected family members in mind do not focus on those family members’ own needs but rather the outcomes for the person using drugs or alcohol. The interventions that are available in the UK fall into two broad categories. There are those that support the family in their own right, such as the 5-step method and mutual aid groups like Al-anon (Fromme, 1990; Orford et al., 2013). Then there are interventions that are delivered through the family’s involvement in the treatment of the person using drugs or alcohol (e.g. social behaviour and network therapy and family therapy) (Copello et al., 2009; Copello, Templeton & Velleman, 2006).

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[20] 1.11.1 The 5–Step Method

Based on the stress-strain-coping-support model aforementioned, the 5-step method aims to systematically provide support to affected family members in their own right (Copello, Orford, Velleman, Templeton & Krishnan, 2000; Copello, et al., 2010a; Orford et al., 2013). The method utilises family members’ coping resources and can be delivered over a series of sessions or in a single session with the aid of self-help material. The five steps are as follows; listening to the family members’ experiences to identify stresses, providing targeted information: reducing stress arising from lack of knowledge, exploring coping responses, identifying and enhancing social support and discussing any additional needs. Evaluation of the 5-step method has shown a reduction in affected family members’ strain (physical and psychological distress) and improved coping behaviours (Copello et al., 2009; Copello, Templeton, Orford & Velleman, 2010b) and improvements were sustained at twelve month follow up (Velleman et al., 2011). The 5-step method has been proven to be adaptable and flexible to delivery by various health care professionals in a variety of settings including primary care and specialist drug and alcohol services, producing positive outcomes (Templeton, 2009; Templeton, Zohhadi & Velleman, 2007). Among primary care health professionals delivering the intervention an improvement was found in attitudes held and motivations to support relatives of people using drugs and alcohol (Copello, Templeton, Krishnan, Orford & Velleman, 2000).

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development of a web based version (Ibanga, 2010) which was found to have equally positive outcomes.

1.11.2. Social and Behavioural Network Therapy

In contrast with the 5-step method, Social Behavioural Network Therapy (SBNT) aims to involve family members and social networks (including friends and colleagues) in interventions for service users to boost positive support for behaviour change (Copello et al., 2009). It is a psychosocial intervention developed in the UK and tested as part of the UK Alcohol Treatment Trial (UKATT). SBNT was found to be cost effective, reduced alcohol use and improved mental health.

1.11.3. Couples Therapy

Behavioural Couples Therapy (BCT), supported by NICE guidelines (2007;2011) is a structured behavioural approach aimed at both improving communication skills and behavioural interactions in the relationship between the person using drugs or alcohol and their partner and promoting abstinence. Efficacy studies have indicated that BCT leads to reduced drinking and improved relationships (Fals-Stewart, et al., 1996).

1.11.4. Non-therapeutic Support: Self-help Groups and Mutual Aid

There are carers support groups all over the UK, usually delivered by charities or drug and alcohol services. They provide emotional support and information to people who identify as carers of someone who uses drugs or alcohol. Carers who attended a carers support group in the West Midlands reported to benefit from emotional support and learning from others (George et al., 2009). Another avenue of support available are mutual aid groups which generally bring people together to address a shared problem, in the form of peer-led support groups and those based on 12-step fellowships (e.g. Al-non, Nar-anon and Families

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Miller, et al., 1999). Al-anon newcomers who were surveyed stated their reasons for attendance were motivated by factors such as the philosophy of al-anon, it’s spirituality, anonymity and group dynamics (Timko et al., 2013; Young & Timko, 2015).

1.12. Help-Seeking

The topic of help seeking is worthy of attention because in order to ensure interventions are useful and effective they need to be accessible to prospective service users. Information about the help-seeking behaviour of adults affected by somebody else’s drinking or drug use is sparse. One way help-seeking has been defined is as “the intentional action to solve a problem that challenges personal abilities” (Cornally & McCarthy, 2011; p286). This theory posits that help-seeking follows a process of defining a problem, deciding to seek help and actively seeking help. There are many psychological factors such as trust, control, fear, stigma and self-esteem which influence help-seeking behaviour. Social factors have also been found to influence help-seeking (George & Tucker, 1996).

An important factor to consider when researching into help-seeking is an individual’s relationship to help (Reder & Fredman, 1996). That is their attitudes, narratives and beliefs about help influenced by societal context and relationships with previous helpers which is likely to influence help seeking behaviour.

Stigma, shame and embarrassment have been noted by previous researchers as potential barriers for relatives of people who use drugs and alcohol seeking help (Ahmedani et al., 2013; Copello, et al., 2005). This is similar to the trends in people who use drugs and alcohol not seeking help (Cellucci, Krogh & Vik, 2006; Cunningham et al., 1993). These factors need to be considered in help-seeking research.

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factors may influence the help-seeking behaviour among the family of people who use drugs and alcohol. However, it has been argued that conclusions drawn from research on help-seeking among referred populations, limits our

understanding of the experiences of those who do not engage with services (Broadhurst, 2003), as people may also seek non-professional sources of help in the form of religion, family, and community support.

My literature search revealed there to be a small number of studies that touch on the topic of help-seeking with regards to adults affected by somebody else’s drinking or drug use. Most attempt to profile or quantify people who seek help. For example, an Australian study sought to uncover the prevalence and profile of people who call the police or seek health care for the effect of others’ drinking (Mugavin, Livingston & Laslett, 2014). They found differences in the profile of people who call the police and people who use health care services. Being older and more educated decreased the likelihood of calling the police because of the drinking of others. Living in regional or remote locations increased the likelihood of contacting health care services. Of note, this study included both people who were affected by the drinking of people they knew and strangers.

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highlights that close proximity does not necessarily increase the likelihood of being affected.

Through qualitative research on family dynamics in Scotland (Barnard 2005; 2006) a theme was noted that most parents would seek help from their GP for advice about their adult son’s and daughter’s drug use but that shame would usually prevent parents generally seeking outside help. Most parents would attempt to resolve the problem within the family because their focus was on the drug use rather than their own needs. Similarly, in a quantitative study in the UK it was found by Howell and Orford (2006) that the majority of people concerned about their partner’s drinking problem sought help for their partner alone. Those who sought help for themselves were more likely to do so when there had been domestic violence.

A quantitative study carried out in Brazil highlighted the importance of services considering the difficulties that families face when trying to access help (Sakiyama, Padin, Canfield, Laranjeira & Mitsuhiro, 2015). Through surveying five hundred family members attending mutual self-help groups, they identified that after discovering their relative’s drinking or drug (cannabis and cocaine) problem there was an average 2.6 years delay in seeking help by 58 per cent of the sample. Help was sought for the range of problems associated with having a relative who uses drugs or alcohol. Family members sought help from doctors, psychologists, therapists, support groups for themselves and support groups for the individual who uses drugs or alcohol. The main reason for the delay in seeking help was that families downplayed the problem and felt that they could cope with the situation themselves. Participants also reported uncertainty about where to find help. The researchers concluded that services should consider that family members have difficulty establishing when drinking and drug use becomes problematic and that shame may drive family members to want to deal with the problem alone.

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unlikely to seek help. Results of a multiple regression showed that predictors of seeking help were providing assistance with daily living and worry (Brown, Biegel & Tracy, 2011). Of note, this research investigated the experiences of caregivers of women with either substance use problems or co-occurring substance use problems and a mental health diagnosis. Participants interviewed were caregivers nominated by the women in treatment so do not capture the experiences of other people who were not nominated and may be affected.

Qualitative focus groups and interviews were conducted in 2007-2008 with carers, service providers and policy makers in North-East Scotland (Orr, Barbour & Elliott, 2013). The research explored carers involvement with services. They found service providers had limited contact with carers and aspired to involve them more. Carers were sceptical that services wanted to involve them to support their loved one or to help them in their own right. They expected drug services to involve them when their relative went into treatment and were surprised when this did not happen or happened in a limited way. The term ‘carer’ was contested. These beliefs about services are likely to discourage help-seeking. Dislike of the term ‘carer’ among some affected family members suggests the need to make sure service promotion material does not inadvertently alienate people with the terminology.

1.12.1. Summary

It is clear from the review that has been presented that there are many ways an individual’s drug or alcohol use impacts on the lives of those around them. Mothers and female partners represent most of the participants in the majority of these studies which may be reflective of the types of family members most likely to take part in research.

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similar issues are faced by affected family members in different locations. However, there are differences in the emphasis of certain stressors in different cultures due to the socio-political context. This highlights the need for research to be carried out in different towns and cities within the UK as well as other

countries so as to consider potential contextual differences.

The areas outlined in this review are unlikely to represent an exhaustive list of the ways a person can be affected by their family member’s drinking or drug use. Instead it reflects factors that are measurable through recorded data and that people are aware of or more likely to report. This excludes potential harms of drug or alcohol use that affected family members do not attribute to the drug or alcohol use or are less likely to report, potentially due to embarrassment, or significance of the impact to their lives.

Few studies state whether the affected family members in their sample use alcohol or drugs themselves. This information would help the reader to consider research findings within the context of how the negative impacts reported by affected family members may be complicated by their own drinking or drug use. Many studies outlined in this literature review refer to drug use or drug and alcohol use in general rather than specific drugs. It is worth considering that the impact of specific types of drugs, alcohol and poly drug use may affect family members differently due to factors such as legality and cultural acceptability, financial implications, associated with alcohol and particular drugs and the impact of psychoactive effects of specific drugs (e.g. acting as a stimulant or depressant) on behaviour.

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Help-seeking research has found that many affected family members are likely to seek help for their relative using drugs or alcohol rather than for themselves and want to be involved in their loved one’s care. There is a discourse of families dealing with the problem alone possibly due to stigma and shame. Variables that influence family members seeking help for themselves appear to be their own mental health issues and experience of alcohol related domestic violence. Research related to help-seeking has been mostly quantitative and profiling. Motivation to seek help has been explored quantitatively but did not explore in detail the nature of worries that encouraged help-seeking. There is scope to explore help seeking experiences in more detail.

1.13. Rationale for The Current Study & Relevance to Clinical Psychology

The impact of drinking and drug use on families has been well documented. Estimates suggest that the numbers of people affected is vast. The severity and cost of harm to family members and society have been established and national policy and NICE guidelines have acknowledged the need for services to support this understated group.

Psychosocial and self-help interventions which address family members’ needs have been developed and proved feasible and effective. However, further research is needed to help bridge the gap between policy, guidelines and practice because there is inconsistency and variation in how policy is implemented in practice across the UK.

Little is currently known about help-seeking behaviours and habits among adults who are affected by somebody else’s drug or alcohol use. The little research that there is, is mainly quantitative and does not explore in detail the factors

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services can facilitate more people to access and benefit from the support which is available.

To my knowledge most of the research in the UK into the effects of drug and alcohol use on family members has been carried out outside of London (e.g. Scotland, West Midlands and South West of England). Therefore, there is a need to conduct similar research in London to explore potential contextual differences in the findings.

Clinical psychologists have a role in delivering psychosocial interventions within drug and alcohol treatment services as well as training and consulting with staff. It is important that staff assess and support wellbeing within the systems around people who use drugs and alcohol in order to improve outcomes for everyone within the network. Currently, there is considerable variation in how much and in what way families, friends and partners of people who use drugs and alcohol are engaged and supported by drug treatment services, carers services and other healthcare services.

I hope that the results of this study will help to inform service planning and policy around how to design services with a better understanding of the types of issues affected others seek help for, how they like to receive help and how affected others can be facilitated to receive the help available. It is hoped that this study will help to bridge the gap between policy and practice by highlighting potential facilitators and barriers to help-seeking that can be addressed.

1.13.1. Aims

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1.13.2. Decision to Research the Effects of Both Drugs and Alcohol I acknowledge that in the UK, there are disparate legal, social and moral implications associated with illicit drug use and alcohol use. I had considered researching the effects of a specific type of drug or alcohol alone on family members. However, given that this is exploratory research into affected family members’ own needs and experiences rather than the needs of the individuals drinking or taking drugs, it felt at odds with the research aims and presumptive to categorise people based on the drug their family member was using (assuming this was even known). Furthermore, given the scant research on the topic of help-seeking, this study will begin to explore whether it would benefit our

understanding for future research to refine the nature of the substance use family members are affected by.

1.13.3. Research Questions

- What is the impact of somebody else’s drug and/or alcohol use on affected family members’ lives?

- What have been affected family members’ experiences of seeking help for themselves? (motivations, challenges and facilitators)

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CHAPTER TWO: METHODOLOGY

2.1. Chapter Overview

I will begin this chapter with an outline of my epistemological position in relation to how I approached the research and reflections on my position as a researcher within the context of the study. This will be followed by an outline of the research design, procedure, participant demographics and ethical considerations. I will conclude the chapter with a rationale for the method of analysis employed for this study.

2.2. Epistemology

Epistemology is a branch of philosophy which refers to how knowledge is

acquired (Willig, 2001). Epistemology is related to ontology (the nature of reality and existence). The epistemological position a researcher takes impacts their choice of method for collecting and analysing data as the choice of research method reflects certain claims and assumptions about how knowledge is acquired.

2.2.1. Epistemological Position

The design and analysis of the current research was approached from a critical realist position: retaining an ontological realism but accepting epistemological relativism. A critical realist view is that there are multiple interpretations of reality because reality cannot be accessed independent of our thinking (Harper, 2012). Thus, I take the stance that there is an ontological reality to drug and alcohol use and its impact on an individual’s family. However, the nature of the impact of an individual’s drug or alcohol use upon another person and the way that its impact is constructed will be influenced by factors such as an individual’s beliefs,

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[31] 2.3. Reflexivity

The critical realist position rejects the positivist notion that researchers are outside observers of objective truth and assumes that research is a social process influenced by the beliefs and values of the researcher. Therefore,

reflexivity is important in qualitative research because it enables the researcher to acknowledge and consider their position within the research process (Willig, 2013).

My interest in this topic of research stems from my clinical and research work experience in substance misuse services in London, prior to commencing clinical psychology training. I became aware that interventions tend to be individualistic, yet service users would often talk about their significant others. Additionally, doing research at a carers’ charity exposed me to the multi-layered impact of an individual’s physical and mental health difficulties on the people close to them. I learnt about the support that they had found invaluable such as respite, advice, counselling and meeting others in a similar situation. However, the numbers of people engaged with the charity who were affected by someone else’s drug or alcohol use was scarce which made me wonder about their experiences of seeking help. I was aware that my previous research with carers might make me more likely to hold presumptions about the needs and experiences of the

participants in the current study. Thus, I was mindful about remaining curious and open to unexpected responses during interviews.

I shared my interest in the study as outlined above with participants and offered to answer any further questions they had about me or the study prior to

interviews. This was done in an effort to create transparency and minimise a potential power imbalance, so that participants would be more open and

comfortable. None of the participants took up the offer to ask further questions, which implies that perhaps my position as a researcher and/or trainee clinical psychologist influenced how comfortable participants felt to ask questions despite my efforts to minimise the inherent power imbalance.

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challenges to seeking help or the unhelpful aspects of help they had received. However, during prior experience of conducting a service evaluation into the reasons why people drop out of an alcohol relapse prevention group, I noticed people were reluctant to make negative comments about the group. This led me to wonder if my position as a trainee clinical psychologist, working within a profession which helps people and is biased towards help seeking being a good thing might make participants more inclined to highlight positive more than negative experiences of help they had received. In an attempt to minimise this, I prefaced these questions with an acknowledgement that seeking help is not always a positive experience.

2.4. Design

2.4.1. Qualitative Research

A qualitative research design was deemed most fitting with the current research aims and epistemological position. Qualitative methods of data collection and analysis aid the in-depth exploration of under researched topic areas (Ritchie, Lewis, Nicholls & Ormston, 2013). It was felt qualitative research would situate people within their context to understand the motivations for help seeking and what underpins decisions and behaviours.

The quality of the research will be evaluated in the discussion chapter using Yardley’s (2008) evaluation criteria.

2.4.2. Rationale for Methodological Approach

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[33] 2.4.3. Recruitment Site

In an effort to explore a variety of experiences, I had planned to collect data from two different London based third sector organisations. Both offer support to family, partners and friends affected by someone else’s drug or alcohol use. However, one of the services required my research proposal to be reviewed by their in-house ethical approval procedure before I could collect data there. This was a lengthier process than anticipated and by the time ethical approval was granted, pragmatically there was not enough time to collect and analysis more data. Therefore, all of the data was collected from one service.

Participants were recruited from a family, partners and friends service in North London. It is a free and confidential third sector organisation for adults whose lives are affected by someone else's drug or alcohol use. The service is attached to an alcohol treatment service and provides; information and advice about ‘addiction’ and treatment, individual support and counselling, support groups, couple and family meetings, workshops and liaison with drug and alcohol

agencies. Support can be offered over the phone or in person. To be eligible for the service, family, partners or friends must be over the age of 18, and either the family member, partner or friend or the person using drugs or alcohol must reside in the catchment area. They aim to support the wellbeing of family, partners and friends in their own right as well as where appropriate help them to support the person using drugs or alcohol in their recovery. The service works closely with a peer led project that runs groups and organises social activities at the third sector site. I visited this service as a researcher and had never worked at the service.

2.5. Procedure

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interviews were unable to be arranged due to work commitments and holidays. I emailed all but one participant an information sheet and consent form to read before we met (see appendix D). One participant did not have an email address so was given time to read the information sheet on the day of the interview. Interviews took place during August and September 2016. The interviews were carried out in a private room at the family, partners and friends service. Before each interview, I checked that participants had read and understood the

information sheet before asking them to sign a consent form. The interviews lasted between 40 and 70 minutes and were audio-recorded. At the end of each interview participants were debriefed by asking them how they were feeling and how they found the interview. They were each given a sheet with a list of support services they could contact should they feel distressed following the interview (see appendix E). This included emotional support services and organisations which provide drug and alcohol information, support and advice. Interviews were anonymously transcribed verbatim by me, the researcher (see appendix F for transcription convention used).

The FPF service have requested a copy of the research findings. I also informed participants that the results would be made available to them. Therefore, a summary of the main themes developed will be produced and disseminated to the service and the participants.

2.5.1. Participant Inclusion and Exclusion Criteria

To be eligible to take part in the study, participants were required to be adults (over the age of eighteen) who self-identify as affected by another adult’s drug or alcohol use; regardless of whether the individual using drugs or alcohol was receiving professional support or not. Potential participants were receiving some form of help for the impact of somebody else’s drug or alcohol use on

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because it would be difficult to separate their own experiences of drug or alcohol use from the impact of someone else’s drug or alcohol use.

The research was open to participants who self-identify as an ‘affected other’ regardless of their relationship to the person using drugs or alcohol. Friends and non-married partners were invited to take part. This is due to the gap in research into systems beyond the immediate family and the acknowledgement that various people within a drug or alcohol user’s system may be affected by their substance use. However, the final sample is made up solely of immediate family members (parents, children and spouses) and this is reflective of the people who were using the family, partners and friends service at the time.

2.5.2. Participants

A purposive sample of eleven participants were recruited. Eight female and three male participants were interviewed. The table below summarises the

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[image:43.842.72.656.93.511.2]

[36] Table 1. Participant Demographics

Participant*

(Gender)

Age Ethnicity Support being

received by family

member Affected by Age Substance used Support being received by person using drugs/alcohol

Charlotte (F) 59 White British

FPF support group, one-one & workshops

Son 30 Alcohol 12 step fellowship

Tariq (M) 62 Pakistani British

FPF one-one & workshops

Son 21 Alcohol,

Hallucinogens & Cannabis

Supported living

Margaret (F) 67 White Irish

FPF support group & workshops

Daughter 32 Primarily Alcohol & occasional Cannabis Residential rehabilitation

Florence (F) 47 White British

FPF one to one, peer led group & workshops

Daughter 29 Alcohol & Cocaine

Not receiving support

Emily (F) 68 White British

FPF one to one & peer led group

Husband 71 Alcohol (in the past)

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Lance (M) 55 White mixed decent

FPF peer led group Wife 55 Alcohol Community detox

Cory (M) 36 White British

FPF one- one Mother Father (deceased)

58 60

Mother using Alcohol (& heroin in the past) Father was using Alcohol, Cocaine, Heroin & Cannabis

Not receiving support

Louise (F) 55 White British

FPF one to one & workshops

Husband 55 Alcohol Not receiving support

Jackie (F) 57 White Irish

FPF support group Used to attend peer led group

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Finia (F) 59 White British

FPF peer led group, workshops (carers group & one to one- elsewhere)

Son 19 Alcohol, Cocaine & Cannabis

Counselling

Martina (F) 67 White Irish

FPF peer led group & one to one &

workshops

Husband, Son & Son’s wife

62 36 42

Husband using Alcohol

Son & his Wife using Alcohol, Heroin & Cocaine

Husband receiving unknown support Son & wife not receiving support

Exploring the Help Seeking Experiences of Family Members Affected by Someone Else’s Drug and/or Alcohol use